26 Tex. Admin. Code § 509.63 - Quality Assessment and Performance Improvement
(a) Each facility shall develop, implement,
maintain, and evaluate an effective, ongoing, facility-wide, data-driven,
interdisciplinary quality assessment and performance improvement (QAPI)
program. The program shall be individualized to the facility and meet the
criteria and standards described in this section.
(b) The program shall reflect the complexity
of the facility's organization and services involved. All facility services
(including services furnished under contract or arrangement) shall focus on
indicators related to improved health outcomes and prevention and reduction of
medical errors.
(c) The program
shall include an ongoing program that achieves measurable improvement in health
outcomes and reduction of medical errors by using indicators or performance
measures associated with improved health outcomes and with the identification
and reduction of medical errors.
(d) The facility shall demonstrate that
facility staff, including the medical, nursing, and pharmacy staff, evaluate
the provision of emergency care and patient services, set treatment goals,
identify opportunities for improvement, develop and implement improvement
plans, and evaluate the implementation until resolution is achieved.
(e) The facility shall measure, analyze, and
track quality indicators, or other aspects of performance that the facility
adopts or develops, that reflect processes of care and facility
operations.
(f) The facility shall
provide evidence supporting that the facility continuously reviews aggregate
patient data, including identification and tracking of patient infections, for
trends.
(g) Core staff members,
including the medical, nursing, and pharmacy staff, shall actively participate
in the QAPI activities, including QAPI meetings.
(1) QAPI meetings shall be held monthly, or
more often as necessary, to identify or correct problems.
(2) QAPI meetings shall be
documented.
(h) The
facility's QAPI program shall include:
(1) an
ongoing review of key elements of care using comparative and trend data to
include aggregate patient data;
(2)
identification of areas where performance measures or outcomes indicate an
opportunity for improvement;
(3)
appointment of interdisciplinary improvement teams to:
(A) identify, measure, analyze, and track
indicators for variation from desired outcomes;
(B) create and implement improvement
plans;
(C) evaluate the
implementation of the improvement plans; and
(D) continue monitoring and improvement
activities until resolution of the improvement plan;
(4) establishing and monitoring quality
indicators related to improved health outcomes, which includes establishing and
monitoring a level of performance consistent with current professional
knowledge for each quality assessment indicator that must influence or relate
to the desired outcomes themselves;
(5) monthly measurement, analysis, and
tracking of at least the following indicators:
(A) infection control (staff and patient
screening; standard precautions);
(B) adverse events;
(C) mortality (review of each death and
monitoring modality specific mortality rates);
(D) complaints and suggestions (from
patients, family, or staff);
(E)
staffing to include orientation, training, delegation, licensing and
certification, and non-adherence to policies and procedures by facility
staff;
(F) safety (fire and
disaster preparedness, use of the Texas Health and Human Services Commission
(HHSC) emergency/disaster notification form, and disposal of special waste);
and
(G) clinical records review to
include treatment errors and medication errors; and
(6) the facility shall continuously monitor
performance, take actions that result in performance improvement, and track
performance to ensure that improvements are sustained over time. The facility
shall immediately correct any identified problems that threaten the health and
safety of patients.
(i)
HHSC may review a facility's QAPI activities to determine compliance with this
section.
(1) An HHSC inspector shall verify
that the facility has a QAPI program, which addresses concerns relating to
quality of care provided to its patients and that the core staff members have
knowledge of and the ability to access the facility's QAPI program.
(2) HHSC may not require disclosure of QAPI
program records, except when disclosure is necessary for HHSC to determine
compliance with this section.
Notes
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